Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation

Background Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings. Methods We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking. Results Small groups (n = 121) and survey ranking (n = 54) were used with distance, remote, and telesimulation as leading terms. Each was favored by a third of the participants without consensus. Conclusion This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of distance, remote and telesimulation is preferred.


Introduction
As healthcare simulation evolved to accommodate public health regulations around social distancing and work-from-home mandates, the ways in which simulations are conducted have changed substantially in many institutions. Simulationists have adapted their curricula, environments and technological framework to accommodate simulations in which learners and facilitators may not all be in the same room [1]. There is a broad consensus that new techniques or technologies are required to conduct effective simulation that accommodates geographical separation of participants, facilitators and equipment [2]. However, the solutions have varied in their approaches. Hybrid instructional approaches utilizing more than one modality or instructional design method are common [3]. The approach in how different centers, instructors and simulation operators have conducted this type of simulation is quite variable.
Duff et al. describe simulation at a distance as 'a novel offshoot of an established discipline (simulation-based education)' [4]. Disciplines evolve more and mature through the development of shared frameworks and vocabulary, and then through applications from in-person simulations and consolidation of knowledge and evidence [5]. Duff et al. also proposed that we are at the edge of a precipice at which a 'development of new vocabulary to describe the new innovations and provide further clarity of definitions' begins [4]. In fact, the Society of Simulation in Healthcare (SSH) Dictionary added a 2020 addendum to define new terms in the literature; these included a variety of terms, including remote simulation, virtual simulation, distance simulation, online simulation and telesimulation [6]. Simulationists in multiple parts of the world anecdotally had distinct impressions, assumptions and preferences for specific nomenclature to describe simulation at a distance.
Therefore, multiple simulation societies met in an effort to formulate a common understanding of the various terminologies describing simulation at a distance and whether a singular nomenclature would be possible.
We present the findings in two parts. First, the results of a large-scale multi-society exercise to determine consensus terminology for geographically distanced simulation activities are presented. We emphasize simulationists' preferences for, and aversions to, potential terms. Second, the results are contextualized through how the three major adjectives, distance, remote and tele-, are used and interpreted in disciplines outside of healthcare simulation.

Terminology consensus exercises (2020)
In the Fall of 2020, We conducted a multistep consensus process using a parallel quantitative and qualitative content analysis design [7] to describe the overall preferences and justifications for terms that best encompasses all simulations when people are not in the same room (i.e. physical or geographical separation). Any wholly digital simulation (e.g. a multi-player serious game) was excluded. We began with an overarching purpose to come to a consensus on the optimal term for simulation with geographical separation. Of note, we consider the terms geographical separation and physical separation to mean the same thing.
The exercises included members from the International Network for Simulationbased Pediatric Innovation, Research, and Education (INSPIRE), International Pediatric Simulation Society (IPSS), Netwerk KinderSimulation (NKS) and the Pediatric Simulation Training and Research Society (PediSTARS) in India. This was a convenience sample of simulation networks. Conference attendees represented one or more of these simulation organizations, and we attempted to include an international group to obtain a diverse perspective with the goal of an English-language consensus. Small group ranking exercises were conducted as part of the Healthcare Distance Simulation Summit on August 14, 2020, using a virtual note board application MURAL (Tactivos, Inc., San Francisco, CA), as noted in Figure 1 and Figure 2 group discussion boards. Then, an individual follow-up survey was administered to another set of participants attending the INSPIRE at IPSSV (International Pediatric Simulation Symposia -Virtual) meeting on October 29, 2020. All terms used in the SSH Dictionary update [6] were introduced as examples in alphabetical order: distance simulation, remote simulation, telesimulation and virtual simulation. These terms were specifically highlighted because their prevalence required an update to the SSH Dictionary. A consultation with a semantics professor outside of the healthcare simulation discipline then confirmed that they were, in fact, all 'orthogonal' in the linguistic sense, defined as no obvious inherent bias in the terminologies. We used a content analysis framework [7,8] for both parts of the consensus exercises to derive themes, with member checking to improve the trustworthiness of this approach [9]. The quantitative portions of the surveyi.e. ranks of preferred terms -were analyzed using descriptive statistics using SPSS version 27 (IBM, Chicago, IL). This study received Institutional Review Board (IRB) exemption from Children's Hospital Los Angeles.

A lack of consensus, but emerging nuances
A total of 121 simulationists in August 2020 and 54 in the October 2020 survey participated. While the exercises yielded no single consensus term, there were three leading contenders. In alphabetical order, the three preferred terms were distance simulation, remote simulation and telesimulation. Table 1 summarizes round 1 findings, and Table 2 summarizes the overall rankings from round 2.

Simulationists' perspectives on terms
We discovered three overarching themes from the consensus exercises that underpinned the groups' justification for the rankings: 1) Physical Distance and Separation, 2) Overarching Nature of the Term and 3) Implications from the Existing Term. Full results are available in Appendix.

Physical Distance and Separation -
This theme was repeated in several iterations across many terms. For many participants, the term was required to convey the sense of physical or geographical distance where telecommunication technology was required to connect participants and/or facilitators. Opinions were divided on the optimal term that represented the geographical distance:

•
'Tele -everyone is outside the room; definition over a distance' • 'Distance encompasses the group being physically distanced from each other' • 'Distance simulation doesn't fully suggest that people are NOT in the same room as this could imply a 6-foot (2 m) rule for COVID-19 precautions rather than remote learning' • 'I think remote accurately conveys that everyone is far from one another but makes it clear that this is not purely virtual' • 'Remote feels too 'distant,' this doesn't need to be miles and miles away'

Overarching Nature of Term -
This was a very prominent theme expressed among all groups. Simulationists struggled with the conflicting desire for a term with adequate specificity versus broad inclusivity. Among those desiring specificity, existing terms lacked information on temporal aspects and technology requirements to successfully conduct the simulation. These resulted in conversations about synchrony or asynchrony, and whether a term encompassed both or not: • 'Virtual: Asynchronous is included, or synchrony is not assured' • 'Distance: Asynchronous implication -passive' Some participants found the term distance too vague or non-specific to suggest the exact nature of how participants were separated in simulation and ranked the term poorly. Within the term tele-, there may be implied technology requirements: • 'Distance is not a precise enough term (how much distance -one room over?)' • 'I interpret remote as more general than distance; allows for more flexibility' • 'I think the semantics of the term "tele-" is more inclusive of the simulation environment. It implies that the simulation is being performed as a typical simulation, just over tele-communications' Terminologies were also criticized or favored depending on whether they invoked required technologies (e.g. teleconferencing software): • 'How do we define "distance"?' and is 'wirelessness' [a] relevant part of definition vs wired?' [sic] • 'Tele-brings to mind a very specific vision of using Zoom(R) and being very distant' Concerns about the use of Telesimulation centered on specifying whether the object of the simulation was to replicate in-person care or telehealth / telemedicine: Finally, further specificity arguments asked for clarity regarding the participants and facilitators, and their interactions. Hybrid simulation was a term that encompassed many types of geographical distribution patterns: • 'One of the following needs to be distant to qualify as telesim: The facilitator, operator or participant' • 'I think we need to categorize along the different domains: 1) participants 2) facilitators 3) physical location 4) time location and 5) authenticity'

Implications from the Existing Term -
The final prominent theme included rationales based on what the English word evokedfrom connotations to related, associated terms. This was the principal theme that suggested virtual simulation would not be favored as a term: • 'Distance: Close to distance learning; joining campuses' • 'Virtual -seems to imply a virtual reality headset' • 'Remote: Smaller cities; resource limited; rural' • 'Tele' is consistent with 'telehealth' and 'telemedicine' Unrelated terms that share the same word roots affected how participants considered the terms such as distance, remote or telesimulation: • 'It makes me think about distance learning -a term that is used for online school programs' • 'As a remote-controlled car or helicopter; the [simulation] is also done remotely' • '[There is] familiarity with teleused for other health-related activities' These associations also led to connotations and implications of isolation, negative emotions or, particularly for telesimulation, connections with clinical care delivery: • 'Distance has a stronger connotation of not being "together" than the rest for me. We are already isolated enough these days!' • 'Remote does not sound very warm!' • 'Tele-is linked to service and not education'

Conceptual analysis of healthcare simulation
We present results from two successive exercises designed to explore unifying terminology for simulations with geographical distancing. Simulationists did not reach a consensus on any of the three terms supported by the SSH Healthcare Simulation Dictionary [6]. Each term was equally preferred in the English language: distance simulation, remote simulation and telesimulation for a variety of reasons. The pandemic forced a very rapid change in healthcare and healthcare simulation practice, and based on our work, it is too early to crystallize into a single terminology. Here, we turn to the considerations that simulationists echoed about the three terms and look towards other disciplines with similar terminology.
Healthcare simulation roots itself on maintaining some level of fidelity to the actual practice of healthcare, whether one-on-one with a patient or among a team surrounding a critical or operative patient. Various aspects of fidelity provide a framework for optimal simulations for learning and are predicated on the idea that clinical care is typically done with in-person teams. Nuances of communication, tactile feedback, situational awareness and even the sense of autonomy and control are played out in a safe learning environment during simulation. The science of simulation does not propose that perfect fidelity is required for optimal learning transfer and experiences. Rather, breaking from perfect fidelity can be both helpful and harmful to learning transfer. The ability to pause a scenario enables reflection-in-action [10]. The ability to remove sensory inputs enables a lower cognitive load for novices [11]. Poor fidelity may conversely lead to learners acquiring incorrect skills or make assumptions about the patient situation.
One could then argue that the COVID-19 pandemic has not only changed the assumptions of healthcare and healthcare simulation in many locales. In considering the urge for new terms, we reflect on the idea that geographical distancing during simulations is a necessary variation in the 'prototypical' mannequin-based simulation secondary to pandemic-mandated physical distancing. Cognitive linguistics explains that new terminologies emerge as subcategories from the prototype require greater specificity [12]. Furthermore, scientific terminologies depend substantially on perspective and expertise, rather than a neutral or absolute definition [12]. In our example, we consider two potential perspectives within healthcare simulation with geographical distance: from within healthcare practice, and outside of healthcare.

Tele-and remote in healthcare practice
Telesimulation is a direct descendent of telehealth and its predecessor telemedicine.
Bashshur proposed that a 'common thread in all definitions of telemedicine (literally, medicine at a distance) to date is the geographic separation between two or more interactants engaged in healthcare' [13]. The expansion to telehealth was a 'more inclusive concept' introduced in 1978 as a more systems-level activity. Without this upgrade in terminology, 'these definitions limit the purview of telemedicine to remote patient care' [emphasis added] [13]. In 1995, Telemedicine first appeared in a scholarly publication journal, entitled as its namesake, Telemedicine [13]. The strong link of telesimulation to healthcare as a system of practice was echoed in our findings.
Remote, in the healthcare world, has been used in terms like remote monitoring. Remote monitoring offers observation and data collection that transcends distance but primarily concerns itself with the technological ability to monitor data. Remote vital signs monitoring, for example, is featured in engineering literature through its innovative technological capabilities [14]. Remote is often used in electronic communications of smart objects and is the preferred term for current digital innovations in the electronics consumer world [15]. Remote control also points to a technological perspective on how to interact. It is likely that simulationists preferring the term remote gravitate towards the technological complexity of conducting simulations across distances, with less focus on the social isolation or systemslevel considerations of distance and telesimulation.
Finally, one term was unanimously voted out. Semantic similarity for virtual simulation to virtual reality contributed to this term's removal before the 2nd survey; the term virtual, as of this writing, evokes the relatively novel technology of virtual reality and the typically marketing-heavy term of 'virtual meeting' that is too specific to a technological modality. While virtual simulation fell out of favor because of the implications of the word virtual, still others felt that distance, remote and telewere reasonably inclusive and could use some modifiers.

Limitations
Simulation networks that participated were a convenience sample, and there is potential for selection bias in that main and byline authors had connections to these networks. We included international simulation societies to obtain a broader linguistic perspective, although this consensus was limited to the English language. Virtual meetings were scheduled via online scheduling polls to accommodate international schedules, although it was impossible to schedule all meetings during daytime business hours for all parties involved given global time differences. Authors put forth an effort to have varied meeting times to be more inclusive of international time zone. Attendees were healthcare simulationists -primarily physicians and nurses who are simulation leaders, but some participants represented other aspects of health care such as medical students or respiratory therapists. This elucidates a limitation of the attendees in that while many simulation experts are in physician and nursing roles, there are others in various other aspects of health care; thus, a broader perspective of simulationists with varying primary professions could have been pursued. We acknowledge that our failure to include authorship from outside of the United States or Canadian is a limitation, and that this may have affected the analysis. Future projects could more actively engage international colleagues beyond the United States and Canada and be more language inclusive.

Distance, tele-and remote outside of healthcare simulation
Thought leaders in other disciplines echo concepts and considerations from simulationists on how the terms distance, teleand remote are used in their fields.
Concerns over the term distance are seen in multiple disciplines for its implication of loneliness or being different. In theology, educators worried about the discordance of the term distance and spiritual formation wherein the 'material absence of physical presence in collective worship was striking' [16]. In engineering, distance education was proposed as a win for women, who could access traditionally male-dominated fields, courses or institutions while balancing home or childcare responsibilities and less inperson harassment. However, there is still a notion of being second-class, inferior, 'or [a] compromise -for women with children and without much free time' [17]. In engineering education, for example, there is a simple problem of unequal access to on-campus university laboratories.
The concept of distance, remote and teleas terms used in higher education generated similar discussions with results comparable to our findings in simulation, starting in the 19th century. The higher education community also used multiple terms without consensus until 1982, when the term distance education was finalized at an International Council for Correspondence Education conference for Higher Education [18]. Some educators were dissatisfied with the forceful implication of geographical separation and wished to emphasize instead the more philosophical paradigm changes, in which agency for learning moves away from a university institution to the learner [18]. Others wanted more technology emphases, leading to terms such as virtual and tele added to distance education.
Furthermore, the idea that knowledge is democratized and accessible led to further terms such as distributed learning [19].

Conclusion
At present, simulationists do not have a full consensus on a single overarching terminology for simulations conducted where the participants or facilitators are geographically separated. The three most favored terms are (alphabetically): distance, remote and telesimulation.
Based on our deepened understanding, it is likely that these three terms will evolve to differentiate each other over time, and a more comprehensive description, rather than a simple term, is necessary for this evolving modality of simulation.

Availability of data and materials
None.

Author Manuscript
Chang et al.